| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2161 |
|
352 |
236 |
$35K |
| D1110 |
Prophylaxis - adult |
341 |
341 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
119 |
119 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
278 |
274 |
$9K |
| D2160 |
|
148 |
110 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
191 |
191 |
$856.23 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
50 |
41 |
$457.68 |
| D0274 |
Bitewings - four radiographic images |
157 |
157 |
$275.43 |
| D0120 |
Periodic oral evaluation - established patient |
211 |
211 |
$198.76 |
| D0220 |
Intraoral - periapical first radiographic image |
352 |
340 |
$69.64 |
| D1208 |
Topical application of fluoride, excluding varnish |
259 |
259 |
$27.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
205 |
117 |
$0.00 |